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Bleeding
definition
dilation of the abdominal aorta (> 3cm) formed by widening of the lumen secondary to weakness of the aortic wall, that may extend proximally or distally along the artery male to female ratio is 8:1 Smoking
Hyperlipidaemia Hypertension Peripheral vascular disease Marfan Syndrome, Ehlers-Danlos syndrome Prevalence of AAA in siblings of patients with known aneurysm is approximately 4 times greater than in individuals with no family history Degenerative aneurysm Hereditary, atherosclerosis
CCF Cardiac
Arterial injury, trauma, angiography, surgery, infection Infection, septic emboli degenerative with possible immunological reaction Hypertension, cystic medial necrosis Incidental finding
Acute limb ischaemia Deep venous thrombosis Infection Dehiscence Incisional hernia
Lower Limbs
Wound Complications Routine examination Ultrasound Sound scanning/Plain Film Abdomen for other reason Patient notices pulsatile mass
Ischemia Reperfusion Syndrome Asymptomatic - 75% Rupture/Leak emergency repair Symptomatic urgent repair Asymptomatic 5.5 cm elective repair to prevent death from rupture Mortality from rupture 75-80%, only 50% reach hospital of which 50% mortality 30 days post-repair Mortality from elective repair 5% 20-25% morbidity Objectives of Surgery:
Rupture Symptomatic - back/flank/abdominal pain, embolisation Rapid increase in size >0.5 cm/year Asymptomatic 5.5 cm exact lower limit controversial Aorto-caval/Aorto-enteric fistula U/S, CT, MR Angiogram 3D reconstruction of images Size/extent of aneurysm abdominal/thoraco-abdominal Relation to renal arteries/involvement of iliac vessels indication
symptoms
70% will have significant coronary artery disease Cardiac co-morbidity results in 75% of operative mortality FBC, ECG, CXR, Stress test, Echo, Coronary Angiogram Exercise tolerance, CXR, ABGs, PFTs Coagulation screen, LFTs, Urea & Creatinine Ruptured aneurysm 66% of ruptures die before reaching hospital 50% peri-operative & postoperative mortality rate i.e. < 20% survival Hypotension Anuria Low Hb Coagulopathy Pre-op cardiac arrest Indicators of Outcome: assessment Fitness for Surgery: Leak
Rupture
60% of aneurysms are suitable Reduced physiological stress Reduced morbidity Reduced mortality Small incisions No laparotomy No cross clamping Rapid recovery Contrast load - renal toxicity Endo-leak Graft migration Suitable of older age groups Suitable in significant co-morbid illnesses Laparotomy Aortic Cross-Clamping Ischaemia-Reperfusion
Feel for pulsatile/expansile mass in 2 planes Why: Listen for bruits Examine femoral and popliteal arteries Size, site and extension U/S - CT Angiography: Tortuosity Involvement of renal arteries Evidence of leak < 5cm:10% 5-5.9 cm:25% >6 cm:35% >7 cm:75% <4cms:0.2cm/year 4-5cms:0.5cm/year >5cms:0.7cm/year Urgent intervention if rate of expansion exceeding the yearly rate !
Rate of expansion: